Crash of a Cessna 402C II off Charlotte Amalie: 2 killed

Date & Time: Feb 8, 1997 at 1932 LT
Type of aircraft:
Operator:
Registration:
N318AB
Survivors:
Yes
Schedule:
Christiansted – Charlotte Amalie
MSN:
402C-0318
YOM:
1980
Flight number:
YI319
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
13000
Captain / Total hours on type:
9000.00
Aircraft flight hours:
16085
Circumstances:
As the flight made a visual approach to the airport from the south over the sea, at night, the pilot changed his navigation radio from the VOR to the ILS system for runway 10 and lost DME reading from the VOR located on a hill north of the localizer course. The localizer showed the flight was south of the localizer course, and without DME from the VOR the pilot believed he was much closer to the island and the airport than the aircraft actually was. As the pilot attempted to make visual contact with the airport and maintain clearance from the hills he allowed the aircraft to descend and crash into the sea about 3 miles southwest of the airport. The pilot had not filed a FAA flight plan for the scheduled commuter flight. The pilot had been flying the route for 5 days and had no previous experience in the area. The pilot reported he had no mechanical malfunctions with the aircraft systems, flight controls, or engines. No FAA Operations inspectors had conducted surveillance on the company's flight operations in the Caribbean since service had begun in December 1996.
Probable cause:
The failure of the pilot to maintain altitude while making a visual approach at night over water in black hole conditions resulting in the aircraft descending and crashing into the sea. Contributing to the accident was the failure of the pilot and operator to use all available air traffic control and navigational facilities, and the FAA Principle Operations Inspector's inadequate surveillance of the operation.
Final Report:

Crash of a Swearingen SA226AC Metro II in Uruapan

Date & Time: Feb 4, 1997
Type of aircraft:
Operator:
Registration:
XA-HAO
Survivors:
Yes
Schedule:
Lázaro Cárdenas – Uruapan
MSN:
TC-356
YOM:
1980
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After touchdown at Uruapan-General Ignacio López Rayón Airport, the crew started the braking procedure and activated the reverse thrust systems when control was lost. The aircraft veered off runway to the right, lost a landing gear and came to rest. All 12 occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Yakovlev Yak-40 near Shushenskoye

Date & Time: Jan 29, 1997 at 1320 LT
Type of aircraft:
Registration:
RA-87552
Survivors:
Yes
Schedule:
Norilsk – Podkamenaya Tunguska – Shushenskoye – Krasnoyarsk
MSN:
9 21 03 21
YOM:
1972
Flight number:
KI160
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
23
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was completing a flight from Norilsk to Krasnoyarsk with intermediate stops in Podkamenaya Tunguska and Shushenskoye, carrying 23 passengers and 4 crew members on behalf of KrasAir (Krasnoyarskie Avialinii). While approaching Shushenskoye, the crew encountered poor weather conditions with a visibility limited to 400 metres due to snow falls. In such conditions, the crew lost his orientation and was unable to locate the destination airport. The captain decided to attempt an emergency landing when the aircraft crash landed in the taiga about 18 km from the airport. All 27 occupants were rescued, among them one passenger was slightly injured. The aircraft was written off.
Probable cause:
The crew lost his orientation in bad weather conditions following navigation error and false calculation regarding the wind component. The lack of ATC assistance was considered as a contributing factor.

Crash of a Beechcraft 200 Super King Air in Seven Islands

Date & Time: Jan 28, 1997 at 1700 LT
Operator:
Registration:
C-GCEV
Flight Phase:
Survivors:
Yes
Schedule:
Seven Islands - Montreal
MSN:
BB-153
YOM:
1976
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total hours on type:
1300.00
Circumstances:
The Propair Inc. Super King Air 200 (serial number BB-153), with two pilots and ten passengers on board, was preparing to make a charter flight under instrument flight rules from Sept-Îles to Dorval, Quebec. At 1700 eastern standard time (EST), the co-pilot, in the left seat, began the take-off roll on runway 09. At an indicated airspeed of about 90 knots, 5 knots below rotation speed (VR), the aircraft began to drift to the left, toward the runway edge. The copilot attempted unsuccessfully to correct the take-off track using the rudder. At around 100 knots, just before the aircraft exited the runway, the co-pilot pulled the elevator control all the way back and initiated a climb. At about the same moment, the pilot-in-command throttled back, believing that a collision with the snowbank at the runway edge was inevitable. The aircraft descended until it struck the snow-covered surface to the north of the runway and slid on its belly before coming to rest on a heading opposite to the take-off heading. The pilot-in-command was slightly injured. The aircraft sustained considerable damage. The occupants used the main door to evacuate the aircraft.
Probable cause:
The aircraft crashed as a result of the lack of cockpit co-ordination when the pilot-in-command took control of the aircraft as the aircraft was airborne. The following factors contributed to the occurrence: marginal environmental conditions; contaminated runway surface; poor cockpit management; ineffective briefing; and, inadequate training for rejected take-offs.
Final Report:

Crash of a Swearingen SA227AC Metro III in Djerba

Date & Time: Jan 11, 1997 at 1900 LT
Type of aircraft:
Operator:
Registration:
EC-GKK
Survivors:
Yes
Schedule:
Madrid – Alicante – Djerba
MSN:
AC-730
YOM:
1989
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
19
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After touchdown, the crew started the braking procedure when the aircraft went out of control, veered off runway and came to rest in a ditch. All 21 occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of an Embraer EMB-120 Brasília in Detroit: 29 killed

Date & Time: Jan 9, 1997 at 1554 LT
Type of aircraft:
Operator:
Registration:
N265CA
Survivors:
No
Schedule:
Cincinnati - Detroit
MSN:
120-257
YOM:
1991
Flight number:
OH3272
Location:
Crew on board:
3
Crew fatalities:
Pax on board:
26
Pax fatalities:
Other fatalities:
Total fatalities:
29
Captain / Total flying hours:
5329
Captain / Total hours on type:
2302.00
Copilot / Total flying hours:
2582
Copilot / Total hours on type:
1494
Aircraft flight hours:
12752
Aircraft flight cycles:
12734
Circumstances:
The flight was being vectored for the approach to runway 3R at Detroit Metropolitan Wayne County Airport (DTW) when the aircraft descended and impacted the ground. The aircraft struck the ground in a steep nose-down attitude in a level field in a rural area about 19 nm southwest of DTW. The flight carried 26 passengers and 3 crew members. There were no survivors and the airplane was destroyed by impact forces and a post crash fire. Instrument meteorological conditions prevailed at the time of the accident. The investigation revealed that it was likely that the airplane gradually accumulated a thin, rough glaze/mixed ice coverage on the leading edge deicing boot surfaces, possibly with ice ridge formation on the leading edge upper surface, as the airplane descended from 7,000 feet mean sea level (msl) to 4,000 feet msl in icing conditions, which may have been imperceptible to the pilots. The pilots had been instructed by air traffic control to slow to 150 knots and according to flight data recorder information, the airplane began to show signs of departure from controlled flight as it decelerated from 155 to 156 knots while in a flaps-up configuration. The investigation disclosed that the FAA failed to adopt a systematic and proactive approach to the certification, and operational issues of turbopropeller-driven transport airplane icing. The icing certification process has been inadequate because it has not required manufacturers to demonstrate the airplane's flight handling and stall characteristics under a sufficiently realistic range of adverse ice accretion/flight handling conditions. The aircraft manufacturer had issued a revision in April, 1996 to the approved flight manual which included activation of the leading edge deicing boots at the first sign of ice formation. The airplane operator did not incorporate the procedure, because it was contrary to the company's trained procedures and practices and of the belief that enacting the changes would result in potentially unsafe operation. Investigators' discussion with management personnel at each of the seven U.S.-based operators of the aircraft indicated that at the time of the accident only two of these operators had changed their procedures to reflect the information in the revision. The FAA, at the time of the accident, did not require manufacturers of all turbine-engine driven airplanes to publish minimum airspeed information for various flap configurations and phases and conditions of flight. During Safety Board investigators postaccident interviews with company pilots, there were inconsistent answers on the complex and varied minimum airspeed requirements established by the company for both icing and nonicing conditions. It was also noted that the pilots uncertainty of the appropriate airspeeds might have been associated with the language used, the different airspeeds and criteria contained in the guidance, the company's methods of distribution, and the company's failure t o incorporate the guidance as a formal, permanent revision to the flight standards manual.
Probable cause:
The Federal Aviation Administration's (FAA) failure to establish adequate aircraft certification standards for flight in icing conditions, the FAA's failure to ensure that at Centro Tecnico Aeroespacial/FAA-approved procedure for the accident airplane's deice system operation was implemented by U.S.-based air carriers, and the FAA's failure to require the establishment of
adequate minimum airspeeds for icing conditions, which led to the loss of control when the airplane accumulated a thin, rough, accretion of ice on its lifting surfaces. Contributing to the
accident were the flightcrew's decision to operate in icing conditions near the lower margin of the operating airspeed envelope (with flaps retracted) and Comair's failure to establish and adequately disseminate unambiguous minimum airspeed values for flap configurations and for flight in icing conditions.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 300 in Apia: 3 killed

Date & Time: Jan 7, 1997 at 1038 LT
Operator:
Registration:
5W-FAU
Survivors:
Yes
Site:
Schedule:
Pago Pago - Apia
MSN:
678
YOM:
1980
Flight number:
PH211
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
At about 1038 hours on Tuesday 7 January 1997, Polynesian Airlines’ DHC-6 (Twin Otter) 5W FAU collided with the western slopes of Mt Vaea, Apia, in conditions of low cloud and heavy rain. The aeroplane was on a scheduled flight from Pago Pago to Fagali’i, and was being flown to Fagali’i by visual reference after having made an instrument approach to Faleolo. The captain and two passengers lost their lives in the accident. The first officer and one passenger survived.
Probable cause:
The following causal factors were identified:
• The decision by the captain to continue the flight toward Fagali’i in reduced visibility and subsequently in cloud.
• Mis-identification of ground features, or an inappropriate heading and altitude flown, as a result of inadequate visual reference.
• Insufficient forward visibility to ensure effective and timely action to avoid a collision with terrain.

Crash of a Casa 212 Aviocar 200 in Kupang

Date & Time: Dec 13, 1996
Type of aircraft:
Operator:
Registration:
PK-NCO
Survivors:
Yes
MSN:
194/37N
YOM:
1981
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing at Kupang-El Tari Airport, the twin engine aircraft went out of control, veered off runway, lost its left wing and came to rest. All six occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Casa 212-A4 Aviocar 200 in Banjarmasin: 18 killed

Date & Time: Dec 7, 1996 at 1523 LT
Type of aircraft:
Operator:
Registration:
PK-VSO
Survivors:
Yes
Schedule:
Banjarmasin – Sampit
MSN:
152/26N
YOM:
1981
Flight number:
MNA5940
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
15
Pax fatalities:
Other fatalities:
Total fatalities:
18
Circumstances:
Shortly after takeoff from Banjarmasin-Syamsudin Noor Airport, while climbing, the crew informed ATC about an engine fire and was cleared to return for an emergency landing. On final approach, the aircraft became unstable, rolled left and right then lost height and crashed on a factory located 2 km short of runway. A passenger was seriously injured while 16 other occupants as well as two people in the factory were killed.
Probable cause:
Engine failure/fire for unknown reasons.

Crash of a Beechcraft 99 Airliner in Fort Chipewyan

Date & Time: Dec 6, 1996 at 1945 LT
Type of aircraft:
Registration:
C-GSFP
Survivors:
Yes
Schedule:
Fort McMurray – Fort Chipewyan
MSN:
U-43
YOM:
1968
Flight number:
3T103
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
12
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On final approach to Fort Chipewayn Airport, the twin engine aircraft was unstable and rolling left and right. Upon landing, the right propeller struck the runway surface. The right engine partially torn off and the right wing was severely bent. The aircraft came to a halt few dozen metres further. All 14 occupants escaped uninjured.